The Changes with Age The interrelationship between age and epilepsy has many facets. Although we tend to gloss over this association in many situations, the age factor is critical in our basic approach to the individual who may experience a seizure - so much so that age-related specialization in the management of convulsive disorders is advocated. There is an age-related manifestation of the convulsive disorders in general, and of epilepsy (recurrent unprovoked seizures) specifically. There are also several specific areas in which the relationship with age requires special consideration. This includes seizure precipitants, seizure (epilepsy) manifestations, seizure (epilepsy) causes, and seizure (epilepsy) prognosis. The consideration of these relationships can further our understanding of basic mechanisms underlying the occurrence of seizures and epilepsy in the human population. Age Specific Incidence of Epilepsy  Anyone interested in evaluating the relationships between age and seizure disorders must study incidence rather than prevalence. Prevalence is the summation of new cases of epilepsy minus those who have died and those who no longer experience seizures. A high prevalence of epilepsy among a population of any age may be due to an accumulation of chronic cases or to a high frequency of newly occurring epilepsy. The use of incidence data allows for a more direct comparison, because cases are identified at the earliest possible point and those that are lost in prevalence studies because of subsequent remission or death are included. Because of these factors, incidence data serve as the primary reference material for this discussion.  Regardless of how one defines the convulsive disorders, the most striking relationship is the age-specific patterns of occurrence. The convulsive disorders have long been considered to affect children predominantly and most frequently to have their onset during childhood. This is in part the result of including febrile (fever) seizures in the broad spectrum of epilepsy manifestations by lay and medically trained individuals alike. Although this perception of an excess of convulsive disorders among children is true, over the past two decades, studies have consistently demonstrated that for seizure disorders the highest incidence is at the extremes of life. In fact, studies in the United States and Europe indicate that the age-specific incidence of epilepsy is higher in those over the age of 75 years than in those in the first decade of life. This striking pattern appears to hold regardless of gender, to be relatively independent of definition of seizure disorder, and to be consistent over time. The pattern can be explained in part by the age of occurrence of diseases associated with the occurrence of seizures and/or identified risk factors for epilepsy, but the pattern of highest incidence during the extremes of life is apparent even among those with unprovoked seizures without an identified cause. One assumes that the high incidence in the young is related to developmental factors - in part genetic. In the elderly, the high incidence of conditions that are risk factors for epilepsy (Alzheimer's disease, cerebrovascular disease, brain tumour) account for a proportion of the increased incidence. Case studies suggest that aging alone may have an epileptogenic effect on the neuron. Descriptive studies also suggest that aging is a definite risk factor for partial epilepsy and possibly for generalized-onset epilepsy. Seizure Precipitants     When one considers the convulsive disorders as a group, one tends to think of epilepsy - that is, the tendency to have recurrent seizures generally without an identifiable precipitating event. Nonetheless, the majority of individuals who will experience one seizure do not have epilepsy; rather their seizure(s) occur only in association with an event that acutely alters the metabolic or structural homeostasis of neuron functioning. In our own studies, we have termed the seizures occurring in these conditions "acute symptomatic seizures". In general, the occurrence of conditions associated with these seizure precipitants is age-related, particularly the external "injuries" that affect the brain. At the time of a stroke or infection of the central nervous system (CNS), 5-10% of those affected will also experience a convulsion. It is clear that the age distribution of those at risk for symptomatic seizures will vary dramatically depending on the underlying condition. Infections of the CNS may affect individuals in any age group, but incidence is highest by far during the first few years of life. Similarly, whereas a stroke may occur in individuals of all ages, the incidence of cerebrovascular problems is clearly higher in the elderly. This same type of age specificity holds for other structural abnormalities such as brain tumours, which tend to occur in the elderly, or severe head injuries, which occur with highest incidence in the young adult. Acute Symptomatic Seizures in Association with Head Trauma                      Head injury has a particular pattern of incidence with a peak during early childhood, a maximum during the teen and young adult years, and a third peak during old age. In general, acute symptomatic seizures occur in direct proportion to the severity of brain trauma, regardless of how severity is measured. Nonetheless, the age-specific occurrence of acute symptomatic seizures in association with brain trauma does not follow the age-specific pattern of incidence of head injury. Given the same degree of trauma, children are much more likely than adults to experience a convulsion in association with a head injury. This increased likelihood of a seizure presumably is related to the increased tendency of the developing brain to manifest convulsions in response to any injury. Acute Symptomatic Seizures in Association with Discontinuation of Alcohol  The peak incidence of heavy alcohol use is in the young adult. The peak incidence of "alcoholism" according to accepted criteria is in the third and fourth decades of life. The peak incidence of a first alcohol withdrawal seizure is in the fifth and sixth decades of life. Although there are may potential explanations for this observation, this age-related anticipation requires further study. Acute Symptomatic Seizures in association with Febrile Illness  Before reaching the age of 5 years, 2-4% of children in the United States can be expected to experience a convulsion at the time of a fever. The convulsive response to fever seems unique to early childhood. About one-third of these children will experience further seizures with fever, however, only a small proportion will experience subsequent unprovoked seizures.  One further relationship should be obvious but has been missed in many articles on this topic: the proportion of individuals who will go on to develop epilepsy is dependent on length of follow-up. Thus, even if the enhanced risk for development of epilepsy is time-limited, the proportion of children with epilepsy in a group of children followed only until the age of 7 years, should be lower than in a group followed for 15 or 20 years. In fact, the increased risk for epilepsy following a febrile seizure remains identifiable at least through the third decade of life. Age and Seizure Type  There are clear age-specific differences in the distribution of new cases of epilepsy when they are classified by seizure type. In other words, the incidence of epilepsy by broad clinical seizure type seems highly age dependent. Epilepsy characterized by seizures classified as generalized in onset predominates through the first five years of life. The incidence of epilepsy characterized by partial seizures is similar to that of generalized epilepsy from this age through adult years, after which epilepsy in the form of partial seizures predominates. In the oldest age groups, the incidence of partial seizures increases dramatically. This increase can be explained in part by the increased proportion of cases attributable to an identified cause. About one-half of new cases of epilepsy in persons over age 65 years are characterized by complex partial seizures. Causes of Seizures and Age  In most studies of epilepsy, a specific cause can be identified in only about 30% of cases. The proportion of cases with an identified cause is age-dependent, as are the specific causes. In children (under 15 years), the preexisting condition accounting for the highest proportion of cases with an identified cause is a neurologic disability from birth manifested as a developmental delay and/or cerebral palsy. Trauma and infections each account for about 5% of cases. Among young adults with newly diagnosed epilepsy, only about one case in six will have a clearly defined cause. Head trauma is still the most frequently identified cause but still accounts for only about 5% of all cases in this age group. In the older adult population, neoplasm and brain trauma each account for about 10% of newly diagnosed cases, although for this age group the most frequently identified cause is stroke or cerebrovascular disease. In the oldest age group studied (over age 64), stroke accounts for almost one-third of all cases, whereas degenerative disease of the central nervous system accounts for an additional 10%.  In all age groups the greatest proportion of cases have no clearly identifiable cause, and even in the oldest age groups, about 50% of cases have no clearly identified antecedent. Age and Remission of Epilepsy  Long-term studies of incidence cases indicate that the prognosis for seizure remission is excellent. About 70% of these individuals can be expected to become seizure-free and to remain so for an extended period of time. Further, it is clear that most people who enter remission may successfully discontinue anti-epileptic medication. Although cause and seizure type are important predictors of remission, studies have shown that age is also an independent predictor of becoming seizure-free. A study controlling for other factors found that individuals with childhood-onset epilepsy are more likely to enter remission and to successfully discontinue medication than are those with onset of epilepsy at older ages. Children who undergo discontinuation (of medication) are more likely than adults to remain seizure-free. Interestingly, those with epilepsy onset during the teen years seem less likely to successfully discontinue antiepileptic medication once they enter remission.  It is clear from the above review that age is an important influence on several aspects of epilepsy and must be considered at many levels. (Article excerpted with permission from Raven Press Ltd., W. Allen Hauser, "Seizure Disorders: The Changes With Age", Epilepsia, 33 Supplement 4, S6-S14, 1992) Life Stages and Epilepsy  That seizures are more or less likely to arise at certain stages of life is generally accepted. However, except for some well-characterized epileptic syndromes, little information is available concerning the natural history of established epilepsy. Puberty  Puberty is a time of rapid and dramatic growth, as well as of psychologic, social, and hormonal change. Puberty might therefore be a time during which epilepsy is more likely to arise and preexisting seizure disorders worsen. Certain epileptic syndromes, such as photosensitive epilepsy and juvenile myoclonic epilepsy, characteristically develop around the onset of puberty, whereas seizures as part of childhood absence epilepsy and benign rolandic epilepsy frequently decrease. However, most seizure disorders are not altered at puberty.  Studies evaluating the effect of puberty on seizures have methodological differences that make comparison difficult. The method of calculating the onset of puberty has not been consistent. Subject groups also have differed in terms of severity of seizures, types of epilepsy, anti-epileptic drug (AED) therapy, and drug levels.  Nevertheless, there is general agreement that seizure frequency is not substantially altered at puberty. An increase in generalized tonic-clonic and complex partial seizures during puberty has been described in some research. Other authors have described transient worsening of seizures in association with rapid growth and suboptimal levels of AEDs, with subsequent return to former seizure frequency and type after the completion of pubertal changes. Complex partial seizures may be less frequent after puberty, a trend that seems to be most pronounced in women. Discontinuation of medication at puberty in children with well-controlled epilepsy is not associated with a greater incidence of relapse than is discontinuation during any other life stage.  There has also been concern that children with epilepsy might have delayed puberty and slowed growth, possibly because of hormonal alterations caused by seizures and/or AEDs. However, recent studies have found that children with epilepsy have normal pubertal onset, growth, and sexual maturation. Menarche  Several retrospective studies have looked at the occurrence of seizures with the onset of menstruation (menarche). Women with menses-associated (catamenial) seizures may be more likely to have seizures begin at menarche.  Preexisting seizure disorders do not respond predictably to menarche. Rosciszewska (1987) evaluated 62 girls with generalized tonic-clonic, complex partial, or simple partial seizures. With menarche, the frequency of seizures was unchanged in one-third, more frequent in one-third, and less frequent in one-third. The seizure type appeared to influence the pubertal response. Most of the girls with partial seizures experienced increased seizure frequency around the time of first menstruation. Menstruation And Epilepsy  A relationship between seizures and the menstrual cycle has been described by many investigators, although others have found no consistent association. In those women with catamenial seizures, vulnerability to seizures appears highest just before and during the menstrual flow and at the time of ovulation. This increased frequency is present in women with idiopathic or symptomatic seizures.  Possible causes for variability in the seizure threshold over the menstrual cycle include changes in body weight and body water, fluctuations in levels of AED's, and changes in brain excitability in response to fluctuating levels of sex hormones. Of these possible mechanisms, sex hormones may most strongly alter seizure vulnerability.  Water retention does not appear responsible for menstruation-associated seizures. Variability of body weight and sodium metabolism over the menstrual cycle is similar in women with and without epilepsy and is not correlated with seizure occurrence.  Several investigators have posited a role for estrogen and progesterone in menstruation-associated seizures. Estrogen may decrease the seizure threshold, creating a time of seizure vulnerability during the menstrual cycle when estrogen levels are high, a suggestion that would explain the observations of increased seizure frequency around the time of menstrual flow.  Progesterone may protect against seizures. The premenstrual period, when seizures in some women seem to be more frequent, is a time of low progesterone production, whereas seizures seem to be less frequent during the midluteal phase when progesterone is maximal. Analysis of urinary excretion of estrogens and progesterones demonstrated a relationship between a deficit in progesterone and higher seizure frequency in women with menstruation-associated seizures but found no association between estrogen and seizures. The progesterone deficit corresponded with lower serum levels of phenytoin, particularly in those women with catamenial seizures, suggesting that altered metabolism of AEDs also may be a factor in the temporal occurrence of seizures. Pregnancy and Epilepsy  During pregnancy, estrogen and progesterone levels increase dramatically and the metabolism of AEDs changes significantly. Either of these factors might be expected to alter seizure frequency. Schmidt (1982) reviewed 27 studies from 1884 to 1980 on seizure frequency during pregnancy. Most women (53%) had no change in seizure frequency, whereas an equal percentage had less frequent (22%) or more frequent (24%) seizures.  Although it has been speculated that changes in seizure frequency reflect hormonal changes during pregnancy, this has not been substantiated. There does not appear to be any consistent tendency for seizures to arise during a particular phase of pregnancy. While some authors have described more frequent seizures during the first trimester of pregnancy, others have noted a small increase in seizure frequency during the third trimester. However, the data are not sufficient for concluding that hormones do not influence vulnerability to seizures in some pregnant women. Menopause and Epilepsy  Very little has been written on the effect of menopause on seizure frequency in women with established epilepsy. Gastaut and Broughton (1972) wrote that menopause could cause "the reappearance of an epileptic condition developed at puberty but absent in the interim". It might be argued that menopause, characterized by low levels of estrogen, would result in fewer seizures, particularly in women whose seizures had tended to cycle with menstruation. In a study specifically addressing this issue, Rosciszewska (1987) reported that seizure frequency was more likely to improve during menopause if there was a catamenial relationship, if seizures began later in life, and if seizures were well-controlled. Frequent partial seizures were likely to become less well controlled after menopause. Epilepsy in the Elderly  The incidence and prevalence of epilepsy increases after the age of 60 years. This increase is thought to reflect a higher proportion of symptomatic epilepsies caused by complications of stroke, cerebral degeneration, tumour, and cardiopulmonary and metabolic disease.  The risk of AED-related adverse effects is higher in the elderly as a result of the biologic effects of aging and changes in drug metabolism. This could cause a higher incidence of anemia, leukopenia, folate deficiency, and neuropsychologic adverse effects, including sedation, sleep disturbance, and confusion.
Seniors and Epilepsy Epilepsy is the third most common neurological disorder seen in the elderly population after dementia and stroke. Accordingly, epilepsy in the elderly is a significant public health issue since there will be a growing number of elderly patients over the next several decades. Currently it is estimated that the annual incidence of epilepsy in persons over the age of 65 is approximately 130/100,000 population. Causes of Seizures in the Elderly  Although epilepsy has generally been thought to be a pediatric disease with onset in childhood it is apparent that there is a second peak in the incidence and prevalence of epilepsy in elderly patients. The causes of epilepsy, however, in the elderly are different than in children or younger adults. The most frequently reported cause is cerebrovascular disease such as stroke. Other less common causes of seizures in elderly patients include tumour and metabolic disturbances, and some seizures are of unknown origin. Seizure Type  The most frequently observed types of seizures in the elderly are partial seizures and secondarily generalized tonic-clonic seizures. In the elderly patient, seizures are often symptoms of some other central nervous system abnormality. Diagnostic Evaluation  As with younger patients the diagnosis of epilepsy in the elderly remains a clinical one. A complete history and physical examination should be obtained from the patient and from an observer. In elderly patients it is particularly important that a careful medication history is obtained.  When diagnosing seizures in the elderly patient one has to exclude fainting spells or syncope, orthostatic hypotension and transient cerebral ischemia. In the elderly, disorders that may predispose to syncope include cardiac arrhythmias, carotid sinus syncope, hypotension and other metabolic disturbances. Trauma should be considered since even minor head trauma in the elderly may result in conditions such as a subdural haematoma. Rarely in the elderly patient neuropsychiatric conditions and movement disorders have to be considered in the differential diagnosis of seizures.  In the elderly patient who presents with recent onset seizures a complete physical and neurological examination should be performed. Certain laboratory studies including serum electrolytes, serum calcium and magnesium, renal function studies, serum glucose, electrocardiogram (ECG), electroencephalogram(EEG) and neuroimaging studies such as CT scan or MRI should be obtained in all patients. Additional studies may be required in individual patients based on the clinical history. These may include cerebrospinal fluid examination, screening for drugs, or evaluation for cerebrovascular disease.  The EEG is a useful adjunct in the diagnosis of seizures in the elderly. However, it is important to keep in mind that the diagnosis of epilepsy is a clinical one and a normal EEG recording does not exclude the possibility of a clinical seizure disorder. In converse, certain EEG changes in the electroencephalogram of the elderly patient should not lead to a diagnosis of a seizure disorder unless the clinical history is also supportive of this diagnosis. Treatment of Seizures in the Elderly  In the elderly patient an accurate diagnosis is of utmost importance. Prior to institution of maintenance antiepileptic drug therapy one has to try to answer three basic questions. These are: Was it a seizure? What type of seizure? What is the underlying etiology (cause)?  The general management of the patient includes reassurance and education for both patient and caregiver. A multidisciplinary approach is often helpful.  In the elderly patient who presents with recent onset seizures one has to ask the question as to whether antiepileptic drug therapy should be initiated. If the patient has been identified as having experienced symptomatic seizures secondary to some correctable underlying disturbance such as an infection, metabolic disturbance or drug withdrawal then these patients do not require antiepileptic drug therapy. However, antiepileptic drug therapy may assist in some circumstances on a temporary basis to suppress seizures while the underlying condition is corrected.  Whether the elderly patient who presents with a first unprovoked seizure requires maintenance antiepileptic drug therapy is more controversial, and the decision to initiate therapy is an individual one. Medications for Epilepsy  Recurrent unprovoked seizures in the elderly require treatment. Potential first line broad spectrum antiepileptic drugs that may be employed in the elderly include carbamazepine (Tegretol), phenytoin (Dilantin) and sodium valproate. Drug trials comparing the relative benefits and side effects of these drugs in the elderly are lacking. In elderly patients one must be particularly concerned about possible sedative and cognitive side effects of antiepileptic drugs.  In addition, in the elderly patient one has to be concerned about the potential for drug interactions since frequently these patients are on medications for other medical conditions. Knowledge of these drug interactions is of paramount importance if adverse reactions are to be avoided. Drugs such as phenobarbital and primidone are less frequently used as first line drugs in elderly patients because of the higher risk of cognitive and sedative side effects of these medications.  Phenytoin is one of the most frequently used antiepileptic drugs in elderly patients. It has certain advantages including once daily dosing and low cost. The disadvantages of phenytoin include the potential for drug interactions and possible neurotoxic effects such as dizziness and ataxia.  Carbamazepine is also a useful first line drug in the treatment of epilepsy in elderly patients. Sedative and cognitive side effects may occasionally be observed. With controlled release formulations twice daily dosing may be possible. The overall risk of serious toxicity from Tegretol therapy is generally small but may be slightly increased in the elderly. In elderly patients carbamazepine may rarely cause cardiac conduction disturbances, mild hyponatremia, and mild fluid retention. Minor drug interactions can also occur between carbamazepine and other drugs that the patient may be on.  Sodium valproate is generally well tolerated by elderly patients. It is less likely to result in drug interactions than phenytoin or carbamazepine. Sedation, tremor, weight gain and gastrointestinal side effects are the most frequent side effects. Hepatic or hematologic toxicity is rare. Valproate generally has to be prescribed in twice or three times daily dosing.  Although comparative clinical studies are lacking, the current treatment choice for the chronic management of elderly patients with epilepsy is phenytoin or carbamazepine initially as monotherapy. The presence of existing medical conditions might influence the choice of antiepileptic drug. For example in patients with known cardiac conduction disturbances valproate or phenytoin may be more appropriate than carbamazepine. If the patient has a gait disorder then carbamazepine or valproate may be the preferred medication. If the patient in on multiple drugs including anticoagulants that may interact with carbamazepine or phenytoin, then valproate may be a good initial choice.  It is probable that elderly patients are more susceptible to the adverse effects of antiepileptic drugs and therefore when initiating therapy one should start with a lower dose than is generally prescribed. The dose should gradually be increased according to clinical effect and with careful monitoring of adverse effects. Although frequently antiepileptic drug plasma levels are monitored, the usually accepted therapeutic ranges are of less clinical relevance in the elderly and the optimal dose of an antiepileptic drug should be based on the clinical response of the patient and lack of significant adverse effects.  Epileptic seizures in the elderly generally respond satisfactorily to antiepileptic drug therapy and the majority of patients obtain good seizure control. If the patient has remained seizure free for two or three years then the physician should review whether the antiepileptic drug can be discontinued. Again this decision has to be individualized for each patient. One has to take into consideration the possible risk of recurrent seizures versus the potential for long term adverse side effects of antiepileptic medications. Prognosis of Seizures in the Elderly  At the present time there are no prospective studies which have specifically addressed the issue of risk of recurrent seizures following a first seizure in elderly patients. Some retrospective studies suggested that over two thirds of patients who had new onset seizures had at least one subsequent recurrence. The question of recurrence in the elderly patient is of particular importance in view of the fact that these patients are more likely to injure themselves during a seizure, the patient may be living alone and may have difficulty obtaining medical help, and some of these patients may already have other disabilities such as a unilateral paralysis from a previous stroke. The impact of repeated seizures in the elderly has a greater impact on the activities of daily living and again this at least in part relates to the presence of other disabilities. Summary and Conclusion  Epilepsy is an important health risk in elderly patients. The etiology of seizures in elderly patients is generally different than younger patients. The principles of treatment are generally similar. The three major antiepileptic drugs in the treatment of seizures in the elderly include phenytoin, carbamazepine and valproate. Phenobarbital and primidone are less useful because of their adverse effects profiles. The role of new antiepileptic drugs such as gabapentin, vigabatrin and lamotrigine has yet to be defined. Interactions between antiepileptic drugs and other medications or concurrent illnesses is of particular concern in patients of this age group. (Dr. Bruni is Head, Division of Neurology, Wellesley Hospital, Toronto, Ontario.) Living with Epilepsy  When seniors experience unusual feelings - lost time, suspended awareness, confusion, seizures - they may think their symptoms are caused by the physical or mental problems that sometimes accompany aging. There may be another explanation for what is happening: they may have become one of the growing number of Canadian senior citizens with late-onset epilepsy (epilepsy that begins in later life).  For a long time epilepsy was seen as a disorder that affects young people, often starting in early childhood; sometimes lasting throughout life. Now we know it can affect anyone at any age. In fact, a look at the statistics shows us that it is as likely to begin in the years after sixty, as it is during the first ten years of life. Having epilepsy at any age takes some getting used to. People want to find out about the disorder, how it is treated, and what kinds of changes it may make in their lives. Causes of Epilepsy  Often there is no obvious reason why someone begins to have seizures. Causes that can be identified however, include severe injury to the brain from accident or other trauma, the after-effects of serious brain infections like encephalitis or meningitis, certain genetic conditions, or changes in metabolism which prevent important nutrients from getting to the brain. Causes of seizures in seniors however, are sometimes related directly to physical changes associated with aging.  Stroke is the most frequent cause of seizures that begin in later life. As people age, arteries may become narrowed or clogged, depriving parts of the brain of blood and oxygen. The result may be damage that produces seizures. Bleeding in the brain, which is another form of stroke, may also leave a person with seizures afterwards. Heart attacks may also temporarily cut off oxygen to the brain, with a similar result.  Diseases such as Alzheimer's, or other diseases that change the internal structure of the brain, may cause seizures. Kidney disease, liver disease, alcoholism and even diabetes may increase susceptibility to seizures in later life.  Brain tumours of any kind may cause seizures. Surgery to remove tumours may be successful in stopping seizure activity in the brain. However, brain surgery occasionally leaves scarring that causes seizures later on.  It is also possible that epilepsy in a senior citizen marks the return of a seizure disorder that was in remission, or it may be the continuation of a life-long disorder. Even when someone has had epilepsy for a long time, it is a good idea to have the treatment reviewed by a neurologist in the senior years. Preventing Seizures  If the underlying cause of the seizures is known, there may be ways of treating it directly, with surgery or medication. However, if direct treatment of the root cause is not possible, the doctor or neurologist will usually prescribe medications to control the seizures.  Antiepileptic drugs (also called anticonvulsants) will usually prevent seizures or reduce their frequency once a certain level has been built up in the blood. This level is referred to as the "therapeutic level" of the drug. To keep the level steady and the seizures under control, the medicine has to be taken every day, on a regular schedule. Missing doses will lower the level of the drug in the blood and make it more likely that seizures will occur. Taking an extra pill in response to an aura or "warning feeling" is not helpful, because the medicine cannot be absorbed fast enough to make a difference when taken orally. By steady, daily use of the medication the blood level of the drug is kept where it should be, and both seizures and side effects are minimized. People using antiepileptic medication should be especially careful not to suddenly stop taking it. Doing so may cause serious rebound seizures that can be life-threatening. Mental Alertness, Mood and Memory  There are a number of health problems associated with aging that affect a person's mental alertness, mood or memory. When a senior who is being treated for epilepsy becomes unusually depressed, confused and unable to remember things, there may be some other explanation.  For example, if the level of the drug in the blood becomes too high, toxicity results. This can often produce these kind of changes. It often takes longer for seniors to metabolize medicines and eliminate them from the body than it takes a younger person. The level in the blood then slowly rises to levels which cause problems, even though there has been no increase in the dose. Also, some older people may have toxic symptoms at levels that don't cause problems in younger people.  Drug interactions are another possibility if unusual symptoms appear. Seniors may be taking other medications besides antiepileptic drugs. They may be taking blood pressure medication, drugs to prevent stomach irritation, insulin for diabetes, as well as medicines for kidney disease or viral or bacterial infections. Some of these medicines may interact with epilepsy drugs. Interaction means one drug changes the activity or effectiveness of another. It may lead to negative side effects or reduce the usefulness of the medicine. Epilepsy drugs of different types may also interact.  It is important for the doctor treating the senior with epilepsy and the pharmacist who fills the prescription to know about all other medicines (including over-the-counter products) being taken to reduce the chance of drug interactions. Also, whenever medications are changed, started or stopped, the doctor should be consulted regarding the effects on the antiepileptic medication.  Seniors may be more sensitive to the depressive effects of a drug (or combination of drugs) than younger people, and these may lead to altered mood and changed behaviour. The important thing to remember is that if a senior who is being treated for epilepsy suddenly becomes confused, depressed, overly fatigued, forgetful, irritable, loses their appetite, gets a rash, or in any way seems different from his or her usual self, the doctor should be consulted and the blood levels checked and, if necessary, adjusted. People may assume that these feelings are just things that have to be accepted as part of the treatment, but that is not necessarily true. Remembering the Medication  As already stated, epilepsy medication works best when the level of the drug in the blood is kept steady. To achieve this, some of the drugs are taken once a day, and some as many as four times a day. It can be hard for seniors to keep track of doses, especially if several drugs are being used daily.  To aid their memory, seniors can use a daily chart, where they record medications and the times at which they are to be taken. A pill box divided into segments according to time of day is also a useful tool. People who live alone may wear a watch with an alarm that sounds when medications are to be taken, or post reminder notes to themselves in places where they're sure to be seen during the day. Marking dates on calendars to re-order medication, and doing so before the prescription runs out, is important in avoiding the risk of seizures if the medication is suddenly unavailable. Living with Epilepsy  Although there are always exceptions, seniors with epilepsy who are otherwise in good health and whose mental abilities are strong, can usually continue to live independently. Families may find this idea difficult to accept. With the best of intentions, they often become overprotective, making the senior relative more dependent than is necessary.  Of course, there are risks associated with seizures. However, making certain changes in the home can reduce these risks. For example, living in a house or apartment without stairs reduces the risk of injury from falls; carpeted floors provide a softer surface, as does using padded furniture and putting protective padding around the corners of tables.  Technology is also available to help people living alone to keep in touch with family members or caregivers. If seizures are frequent, portable phones or pagers provide a way to call for help from any part of the house.  Fire, heat and water are potential hazards for people with seizures at any age. This is because people do not feel pain during seizures and are therefore unable to protect themselves. Although they cannot be completely avoided, some simple precautions can reduce these risks as well: Don't smoke. Having a seizure while smoking could cause a fire. Use a microwave oven for cooking. Serve food where it is cooked to avoid carrying pots of hot food. Heat water by the cup in the microwave (rather than boiling a kettle) for tea and coffee. Avoid appliances such as electric carving knives, irons or space heaters with open heating elements, hot surfaces or unstable stands. Set the temperature on the water heater low enough to prevent scalding. Keep electrical appliances away from sources of water. Keep bathtub levels low, or shower using a hand-held shower with no plug. Wear rubber gloves when washing or handling breakable objects. Keep a screen in front of an open fire; allow hot ashes to cool before moving them. Then and Now  Senior citizens can remember a time when there were no reliable treatments for epilepsy. As recently as the 1940's people did not understand why seizures happened and they were afraid of them. Families often sent people with epilepsy to live in institutions, or kept them isolated in the home. People with epilepsy were sometimes prevented from marrying or immigrating, and epilepsy was sometimes regarded as a type of mental illness.  Not surprisingly, people who remember these situations may need reassurance that things have changed. Epilepsy is now a well-understood neurological disorder, no more mysterious than other physical conditions. Today we know that epilepsy is not contagious, not a mental illness, not a symptom of intellectual decline and certainly not a reason for shame or family embarrassment. Epilepsy can often be successfully treated, and even if seizures continue to happen sometimes, that need not prevent a healthy, active senior citizen from living an independent and satisfying life. (Excerpted with permission from Seniors and Seizures, a brochure by Epilepsy Canada, 1995.)